A simple MRI technique for the assessment of thoracic outlet compression syndrome (TOCS)

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1 A simple MRI technique for the assessment of thoracic outlet compression syndrome (TOCS) Poster No.: C-3128 Congress: ECR 2010 Type: Scientific Exhibit Topic: Vascular Authors: E. Fanou, M. Cowling; Stoke-on-Trent/UK Keywords: Thoracic outlet compression syndrome, Magnetic resonance imaging, Vascular disease DOI: /ecr2010/C-3128 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 30

2 Purpose Background: Thoracic outlet compression syndrome (TOCS) is a complex topic, due to the variation in the clinical presentation and lack of sensitive clinical and imaging diagnostic tools. Even the name itself is debatable, because the actual site of pathology is technically the thoracic "inlet," not the "outlet''. However, by common usage the term TOCS has been established in the literature. TOCS is a broad term that refers to compression of the neurovascular structures in the cervico-axillary canal. The symptoms are variable, depending on the anatomical structure compressed, and is a rather dymanic pathologic entity. The brachial plexus (95%), subclavian vein (4%), and subclavian artery (1%) are affected, as they cross through the three anatomic spaces within the thoracic outlet (figure 1 on page 4); these are the interscalene triangle, the costoclavicular space and lastly the retropectoralis space. Anatomy: The brachial plexus trunks and subclavian vessels are subject to compression or irritation as they course toward the axilla and the proximal arm. The most important of these passageways is the interscalene triangle (figure 2 on page 6: normal interscalene triangle) This triangle is bordered by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the medial surface of the first rib inferiorly. This area may be small at rest and may become even smaller with certain provocative maneuvers. Anomalous structures, such as fibrous bands, cervical ribs, and muscle hypertrophy, may constrict this triangle further. The second compartment is the costoclavicular space (figure 3 on page 6:normal costoclavicular space), which is bordered anteriorly by the middle third of the clavicle, posteromedially by the first rib, and posterolaterally by the upper border of the scapula. The last compartment is the retropectoralis (subcoracoid) space (figure 4 on page 7: normal retropectoralis space), beneath the coracoid process just deep to the pectoralis minor tendon. Subtypes of TOCS and associated symptoms Page 2 of 30

3 1. Neurogenic (most common) - compression of brachial plexus Numbness or tingling of the fingers Pain in the shoulder and neck Ache in the arm or hand Weakening grip 2. Vascular - subclavian vessel compression Discoloration of the hand (bluish color) Subclavian vein thrombosis Arm pain and swelling Throbbing lump near the clavicle Pallor in one or more of the fingers or your entire hand Infarcts of the fingers 3. Non-specific type Chronic pain in the area of the outlet but specific cause not determined Diagnosis and imaging investigation of TOCS Clinical history, physical examination and provocative clinical tests that can reproduce the symptoms, usually elicit the diagnosis Nerve conduction of the ulnar and median nerves and Electromyogram studies are the most helpful adjunctive tests, to exclude other peripheral nerve causes of symptoms Plain film can demonstrate bony abnormalities at the thoracic outlet Doppler US maybe helpful in some instances although there are mixed reviews in the literature CTA can demonstrate arterial compression but there are the disadvantages of ionizing radiation exposure and iodinated contrast administration MR Thoracic Outlet is gaining ground and is now considered by many to be the preferred method for Thoracic Outlet Imaging Catheter angiography- is still consider by many the ''gold standard'' for vascular imaging Purpose The aim of our study was : To assess the incidence of vascular/arterial compression, in MRI imaging, in symptomatic patients To assess the accuracy of MRI in identifying the anatomical compartment of compression, and the structural anatomic abnormality causing the compression Page 3 of 30

4 To demonstrate major discrepancies in radio-anatomic correlation of findings To review the accuracy of detecting fibrous bands in MRI, as a cause of TOCS To assess the incidence of significant incidental findings on MRI Images for this section: Page 4 of 30

5 Page 5 of 30

6 Fig. 1: Demonstration of the compartments of the thoracic outlet and their components. AS = anterior scalene muscle, BP = brachial plexus, C = clavicle, CC = costoclavicular space, IT = interscalene triangle, MS = middle and posterior scalene muscles, Pmi = pectoralis minor muscle, RP = retropectoralis minor space, SA = subclavian artery, SM = subclavius muscle, SV = subclavian vein. Fig. 2: Sagittal T1W MRI demonstrates normal scalene triangle. Page 6 of 30

7 Fig. 3: Sagittal T1W MRI shows normal dimensions of the costoclavicular space. Page 7 of 30

8 Fig. 4: Sagittal T1W MRI shows normal dimensions of the retropectoralis space. Page 8 of 30

9 Methods and Materials We conducted a retrospective study. 53 symptomatic patients, who had been seen by a vascular surgeon, specializing in thoracic outlet decompression, were referred for imaging of the thoracic outlet region from 02/ /2009. All patients had been reviewed in the clinic, had undergone physical examination and there was clinical suspicion of TOCS, but not all of them had a definite clinical diagnosis. Imaging were obtained using a 1.5 T ACHIEVA NOVA Philips Magnet. Our institution's standard protocol for the Thoracic Outlet imaging is [1]: sagittal T1W images with the arm positioned along the body (neutral position) and with the arm in hyperabduction, and coronal T1W images throught the upper thoracic region. 2 patients were excluded from the study, because their symptoms were related to post-operative complications. Subsequently, after imaging evaluation, 9 have so far undergone surgical decompression of the thoracic inlet. The operative notes were reviewed, regarding the intra-operative findings and these were correlated to the imaging findings for radio-anatomical correlation. In our study we also evaluated the pick up rate of incidental significant findings. Results Page 9 of 30

10 51 patients were included in our study; 13 men and 38 female, with a mean age of 42.6 (18-74) 29 out of the 51 patients, 56.8%, who underwent MRI had abnormal structural anatomical findings, but not all of those had arterial compression In 22 of the studies the thoracic outlet was completely normal, but in two of those significant incidental findings were demonstrated 1 Of the remaining 29 abnormal scans, arterial compression was demonstrated in 24 cases, 82.7% (47.1 % of the 51 patients originally referred with clinical suspicion of TOCS). 1. In 5 cases the compression was bilateral, nevertheless the symptoms were unilateral 2. In 2 cases there was a degree of compression in the neutral position 9 have undergone surgery so far - In one case arterial compression was not demonstrated on MRI; nevertheless surgical decompression was performed on the basis of the clinical diagnosis (1: arterial compression is considered to be any change in the caliber of the artery or change in it's diameter) Symptoms (in descending frequency) in the 29 cases with abnormal MR anatomic findings: 48.3 % of the patients had a combination of arterial and neurological symptoms. The most frequent symptomatology, as it was documented in the patient's notes was: 1. Neurological symptoms were found in 82.7% (n=24/29), in form of pain with dermatomal distribution sensasion loss numbness or paraesthesia 2. Arterial symptoms in 58.6 % (n=17), in form of either ischaemic changes digit discolouration digit coolness 3. Decreased mobility of the affected side 6.9 % (n=2) Page 10 of 30

11 In the remaining 22 normal cases that were referred for imaging, the presenting symptoms were: Neurological symptoms: in 81.8%, n=18 Arterial symptoms in 36.4%. n=8 4 patients had a combination of neurologic and arterial symptoms Imaging investigation of patients with abnormal MRI findings Plain Cervical spine X Ray : % (n=25) had a Cervical Spine X-Ray 2. In 51.7% (n=15) it was the first imaging examination Doppler Ultrasound : % (n=11) had a Doppler-Ultrasound 2. In 10.3% (n=3), Doppler-Ultrasound was the first imaging investigation 3. In 34.5% ( n=10) the study was normal. Of these, concordance with the MRI findings was demonstrated in n=3 (30%), whereas in n=7 (70%), MR showed compression of the subclavian artery CTA was done in n=2 patients - one as CTA for suspected aortic dissection Angiography performed in n=1 patient, and subclavian occlusion was demonstrated N=1 patient underwent MR angiography Anatomical abnormalities at the Thoracic Outlet Region, as demonstrated on the MRI study: Prominent C7 transverse process in n=13 (out of 29) Fibrous band was seen in n=9 Cervical rib in n=6 Hypertrophic scalenus muscle in n=3 In n=2 patients there was abnormal insertion of the scalenus muscles; in n=1 abnormal insertion of the scalenus medius and in n=1 of the scalenus posterior. In the latter case hypertrophic transverse process of T1 and T2 was also demonstrated with abnormal superior position of the ribs. In n=3 cases no specific anatomical abnormality was seen. Arterial compression demonstrated In the scalene triangle: n=15 (out of 24), 62.5% Page 11 of 30

12 In the costoclavicular space: n=9, 47.5% In the retropectoralis space: n=0 First case: 46 year-old female presented with sensation loss of the lateral ulnar aspect of the left arm. MRI of the thoracic outlet shows hypertrophic transverse processes of the seventh cervical vertebra (fig 1 on page 15). On the left there is a bony spur and a prominent fibrous band which is causing compression of the subclavian artery as it exits the scalene triangle. Figure 2 on page 15 in the neutral position and figure 3 on page 16 in hyperabduction. Second case: MRI of a 36 year-old female with neurological symptoms on the left shows marked compression of the subclavian artery as it passes through the infraclavicular space between the mid clavicle and first rib. There is also evidence of neural compression at the same site. Figures 4 on page 17-5 on page 17. Third case: The MRI of a 52 year-old female with left sided C6 symptoms, pins and needles at the right hand, abnormal nerve conduction studies on the left, shows impingment of the tip of the tip of a cervical rib (arrow in figure 6 on page 18) onto the nerve roots within the scalene triangle. There is also arterial compression, which is very significant in the hyperabducted position (figures 7 on page 19-8 on page 20). Fourth case: MRI of a 47 year-old female, with arterial and neurologic symptoms, shows severe compression of the subclavian artery at the costoclavicular space (figures 9 on page on page 22). Fifth case: The MRI of a 45 year-old female with blue, discoloured, swollen right hand with associated weakness and muscle wasting, shows compression of the subclavian artery within the scalene triangle, due to bulky anterior scalenus muscle (figures 11 on page on page 24). Sixth case: The MRI of a 56 year-old male with paraesthesia and coolness of the left forearm, shows compression of the left subclavian artery as it exits the Page 12 of 30

13 scalene triangle due to a fibrous band (figures 13 on page on page 26). Seventh case: The MRI of a 43 year-old female with bluish discolouration of the fingers, shows prominent transverse processes of the C7 bilaterally (figure 15 on page 26). On the right there is a fibrous band extending from its tip to insert into the first rib postero-inferiorly to the subclavian artery. Subsequently the latter is compressed in hyperabduction as it enters the costoclavicular space (figure 16 on page 26). Radio-anatomic correlation: Concordance between the radiologic findings and the intra-operative findings was found in n=2 cases (out of the 9), 22.2%, in both cases of a fibrous band. However the intraoperative identification of a fibrous band as a sole cause of compression is difficult due to the nature of the operation. Significant indicental findings: In the abnormal studies: 1. In one patient abnormal configuration of the exit foramina was demonstrated and Schwannomata were diagnosed. 2. Demyelinating changes were demonstrated in one patient, which raised the possibility of Multiple Sclerosis 3. In three patients degenerative changes were demonstrated In the normal studies: 1. One patient with reduced hand sensation and absent pulses, was found to have myelomalacia changes on MRI. 2. One patient with paraesthesia and neurologic symptoms was found to have Chiari type 1 and syringomyelia. Page 13 of 30

14 Page 14 of 30

15 Images for this section: Fig. 1: The prominent transverse processes of C7 as shown on the coronal T1W images.on the left side there is a prominent fibrous band arising from the process and causing the arterial compression in the scalene triangle. Page 15 of 30

16 Fig. 2: Sagittal T1W MRI shows on the left side hypertrophy of the transverse process of the C7 (demonstrated on figure 1). There is a fibrous band which is causing compression of the left subclavian artery as it exits the scalene triangle. Fig 2 demonstrates the subclavian artery within the scalene triangle in the neutral position. Fig 3 demonstrates compression of the artery in hyperabduction, caused by the fibrous band. Page 16 of 30

17 Fig. 3: Sagittal T1W MRI shows change in the subclavian artery calibre in hyperabduction, caused by a fibrous band. Fig. 4: Sagittal T1W images shows a normal infraclavicular space in the neutral position. Page 17 of 30

18 Fig. 5: In the same patient as in figure 4, in hyperabduction there is significant narrowing of the infraclavicular space and change of callibre in the subclavian artery. Page 18 of 30

19 Fig. 6: Sagittal T1W MRI shows a cervical rib (arrow). Page 19 of 30

20 Fig. 7: In the same patient as in figure 6 in abduction there is compression of the subclavian artery within the scalene triangle, between the anterior scalenous and the cervical rib. Page 20 of 30

21 Fig. 8: A consecutive image in abduction, of the same patient in figures 6-7 with the cervical rib, shows more clearly the arterial compression. Page 21 of 30

22 Fig. 9: In another patient, normal appearance of the costoclavicular space in the neutral position. Page 22 of 30

23 Fig. 10: The same patient, as in figure 9, in abduction shows marked narrowing of the costoclavicular space and significant compression of the subclavian artery. Page 23 of 30

24 Fig. 11: Sagittal T1W MRI in the neutral position, shows slight abolition of the fat anteriorly to the subclavian artery, within the scalene triangle and a bulky anterior scalenus. Page 24 of 30

25 Fig. 12: In hyperabduction, in the same patient as in figure 11, there is compression of the subclavian artery by the bulky anterior scalenus muscle. Page 25 of 30

26 Fig. 13: Sagittal T1W MRI in the neutral position, shows slight abnormal arterial calibre within the scalene triangle and a fibrous band anteriorly to the subclavian artery. Fig. 14: In hyperabduction, in the same patient as in figure 13, there is significant compression of the subclavian artery, due to the fibrous band. Fig. 15: Coronal T1W MRI in neutral position shows prominent transverse processes bilaterally, with an associated fibrous band, on the right side, extending from its tip to the first rib (arrow). Page 26 of 30

27 Fig. 16: In hyperabduction, corresponding to figure 15, the subclavian artery is compressed within the scalene triangle, and the fibrous band can be seen posteroinferiorly to the artery. Page 27 of 30

28 Conclusion In our study we found that arterial compression was demonstrated in 47.1 % of the referred patients with clinical suspicion of TOCS; the detection rate was less than that found in the study by Demondion et al 2003 [1]. This difference is probably due a difference in the inclusion criteria. We have imaged a cross section of patients with the clinical diagnosis ranging from "definite" to "unlikely", whereas Demondion et al compared patients with a definite clinical diagnosis to normal volunteers. The results regarding the anatomic compartment of arterial compression were comparable with their symptomatic group. The radiological correlation of the MRI and intra-operative findings was not possible, in some cases due to the poor quality of documentation, or due to difficulty in the identification of the anatomical abnormality because of the nature of the surgery. This is a particular issue with fibrous bands. The demonstration of the anatomical abnormality, in case of a cervical rib or prominent transverse process was superior on MRI than on a plain radiograph. A cervical rib was identified or commented upon a plain cervical radiograph in 50% of the cases seen on MRI, whereas in case of a prominent C7 transverse process the pick up rate was 38.5 %. This may relate to the reporting of the plain films by individuals without a specific interest in this area. In our institution Doppler Ultrasound was performed in 37.9 % of the referred patients, however, concordance with the MR findings was demonstrated in 27.3 % (n=3 out of 11 who had ultrasound). Therefore we found that Doppler US was not particularly helpful in the detection of arterial compression. In conclusion, even though conventional angiography is considered by many to be the gold standard in the diagnosis of arterial TOCS, MRI Thoracic Outlet is a promising noninvasive, non-ionizing, non-contrast technique. It can provide confirmation of arterial compression and can also give accurate information with respect to the anatomical abnormality causing the vascular compression, which would not be provided by a catheter angiogram. Page 28 of 30

29 References 1. Thoracic Outlet: Assessment with MR Imaging in Asymptomatic and Symptomatic Populations, Xavier Demondion, Radiology, Imaging Assessment of Thoracic Outlet Syndrome, Xavier Demondion, Radiographics, 2006 Page 29 of 30

30 Personal Information E. Fanou, MD, M. Cowling, MBBS, FRCR, Department of Radiology, University Hospital of North Staffordshire, Stoke-on-Trent (mail to : tzenif82@yahoo.gr) Page 30 of 30

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